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Incident reporting and open disclosure

Sept-Oct 2017

As I write, New Zealand is gearing up for a General Election. Over the last two years we have watched other countries struggle with change processes – now it’s our turn.  The public’s interest in this election was reinvigorated following the resignation of Andrew Little (well done mate, cannot have been easy) and Jacinda Ardern stepping up to the leadership and forging a connection with the electorate. There have been a few casualties, Metiria Turei gone and Winston Peters is having some speed wobbles.  Gareth Morgan has had a crack at Jacinda which so far seems to have backfired – bit of a shame as I quite like many of his party’s policies, although not sure how he is going to fund his tax cuts. This has stimulated some robust political debates in my household, with four daughters who think Jacinda is the “bee’s knees.”

I have been involved in a few other debates recently, mainly related to the HDC case 16hdc00882. This case has stimulated a number of conversations, which long term may be of immense benefit to our community, including:

  • The HDC process
  • Drug safety
  • Safersleep and how we integrate this into our practice, especially at critical times such as induction and crisis management.
  • Incident reporting and open disclosure.

I would like to touch on these issues, specifically incident reporting and open disclosure. Many have expressed concern that Dr B’s honesty and open disclosure got him into more trouble and perhaps he should have kept quiet.

Incident reporting is a complex process – there are potential fish hooks and it is not as simple as it might initially seem.  Some recent articles provide insight on this topic and are useful to reflect on. Similarly, the legal review that the Society commissioned from Jonathan Coates on the HDC case provides some guidance. I will include some quotes from this legal review but also recommend you take the time to read it in its entirety. (This can be accessed from the NZSA website under the About/Advocacy tab on the home page but you must be logged in as it is available to members only.)

Anaesthesia is often compared to aviation, as there are many similarities. There are also a few important differences. The most obvious is that we don’t go down with the airplane; although anyone who has been through an investigation may dispute this. Another difference is that we are expected to operate with an often out-of-date aircraft with multiple systems failing in conditions that any sane pilot would refuse to fly in.

Professor Alan Merry and B Henderson (a pilot) discussed incident reporting for anaesthesiology and aviation in an AIC editorial earlier this year. The timing of this article could not have been better – it’s almost if the authors anticipated the current debates we are having. (1) Incident reporting has positive outcomes; it promotes learning but also demonstrates our concern to the public that we prioritise safety and are constantly striving to improve. They also refer to the downsides, such as the fear of retribution which impedes voluntary reporting. Anonymous reporting negates some of this but introduces other issues, such as malicious reporting. One would hope this is not a problem we have to deal with.  Ideally, we will move towards what is known as a “Just Culture” paradigm in which:

  • “The approach to accountability distinguishes the inevitable failures that occur in complex systems that include humans from more infrequent events that may justifiably be considered blameworthy.”
  • “Normal human error that is openly disclosed should be encouraged, and no blame should follow, but clearly if there has been failing or violation appropriate sanction must occur.”
  • And arguably the most important bit but hardest to apply: “The approach is not binary, and sanctions should reflect the circumstances.”

I would like to briefly look at the concept of Just Culture; I think that there is more to this than meets the eye. I am fortunate to work amongst colleagues, both past and present, who have worked hard to create this culture and I have witnessed this culture when visiting other anaesthetic departments. It is more than simply an environment in which one can report incidents without fear of retribution. In fact, for learning and improvement to happen, it may be appropriate that from time-to-time one’s practice is criticised for reasons such as:

  • out of date practice
  • incorrect use of new technology
  • poor assessment
  • violation error etc.

The key is that criticism should be done in a way that is supportive and non-judgmental. Personally, I have learnt from listening to others talk honestly about their mistakes and am most grateful to these colleagues for their honesty.

I have also had to look critically at my own practice and modify what I do. Hence, the concern of many about this particular case; a colleague has honestly reported a mistake and seemingly been punished for it. This is an interesting reminder about the difficulty of maintaining a Just Culture. It can take very little to destroy a culture of trust and honesty that has taken time to build. I would like to suggest that in fact Dr B hasn’t been punished and that the judgement of breach was simply recognition that he made a mistake (storage of drugs) that the commissioner sees as inherently risky (paragraph 47) (3). I accept that to us, as medics, the judgement of breach may seem like a punishment. However, no further remedial action has been suggested. I would also suggest that Dr B had no choice but to follow the path that he did and will refer to a recent BJA article about open disclosure “Duty of Candour”. (2) (again, these authors must have anticipated our situation) and to Jonathan Coate’s report.

So, from the BJA: As a profession (medicine) we do not have a strong record in relation to open disclosure. The article cites an extreme example from 20 years ago, of a young man with Addison’s disease who was mismangaed and died. The subsequent cover up, backtracking and falsification at multiple levels is shameful but it is worth remembering so that hopefully it doesn’t happen again. A more recent quoted example is the Mid-Staffordshire Trust enquiry and report by Sir Robert Francis QC, which led to the Duty of Candour of the Health and Social Care Act 2008 being introduced (in Britain) in November 2014.  This is the first legislation of its kind in the world. It complements and bolsters the existing professional and contractual DoC requirements, but in addition, is enforceable by law.

I have personally struggled with what threshold of incident to disclose to patients. I have listened to colleagues discuss cases and their threshold for disclosure is sometimes different to mine. At the extremes, there is usually no debate. Indeed, as pointed out by Jonathan Coates in his report:

“‘open disclosure’ – and any practitioner who chooses not to disclose a known mistake that has adversely affected a patient runs the risk of criticism that is likely to be more severe than what would be made in relation to the initial mistake.”

The BJA article offers some guidance here:

“The qualifying thresholds and semantics within the legislation are important. A notifiable safety incident is defined as ‘any unintended or unexpected incident that in the reasonable opinion of a healthcare professional could result in, or appears to have resulted in

  1. a) the death of the service user . . . or
  2. b) severe harm, moderate harm or prolonged psychological harm to the service user.”

They then go on to define severe and moderate.

After talking with a wise collaegue, I suggest it is subtly more difficult than this paper would have us believe. And it comes back to communication and perception. If a patient perceives that they have been wronged in some way, and inadequate corrective action taken, then arguably we have failed that patient.  I believe that this results in complaints. In reality, the bar is much higher than the above legislation suggests. In modern anaesthetic practice we often have very little time to build rapport with, and gain the trust of patients. If we have to relay bad news we are often doing this with minimal relationship foundation. So, our communication skills – contrary to what is often thought – must be extremely well honed. In fact, we are quite good at this and as the BJA article points out, our surgical colleagues often leave this task to us.

Although our aim is zero harm, it is unachievable – we are human, we make errors but we therefore must reduce errors and optimise our responses when error occurs. To close the loop and come back to case 16HDC00882, the response of Dr B was exceptional and a fine example for us.

There has been much to reflect on and learn from in this case as I have summarised above. I know that both Dr B and the commissioner had hoped we would reflect on, discuss and learn from this case.

As a community, we must continue to strive to create and maintain a Just Culture – it is in the best interests of our specialty, our patients and our community.

May the force be with you.



  1. Merry A, Henderson B; Incident Reporting Aviation and Anaesthesia. AIC 2017, 45:4 pp 291-293.
  2. Wijesuriya JD and Walker D, Duty of Candour: a stautory obligation or just the right thing to do? BJA 2017, 119:2, pp175-177.
  3. 16hdc000882